05.23.13
by

On EKGs and Bicarb for Hyperkalemia

Just watched Amal Mattu (and Andy Neill’s) great EKG review, this time on (spoiler alert) — hyperkalemia! (If you’re not watching these videos, you’re missing out on free, amazing education from I think the best EKG teacher in the world.)

But I think there are two things worth mentioning:

You cannot — and should not — use an EKG to “rule out” hyperkalemia. I completely agree with Amal — if you see a bizarre looking EKG, you should think tox, potassium or calicum derangement (I like to throw LBBB in there too), but a normal EKG won’t rule out diddly squat in your patient. A few studies-in-point:

The Ability of Physicians to Predict Hyperkalemia From the ECG: Took patients with known hyperkalemia in the ED, had two physicians use the EKG to determine if the patient had hyperkalemia: sensitivity around 0.4; specificity around 0.85. Not great.

Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients: Took dialysis patients, got a pre-dialysis potassium level, and looked at T waves, R waves, ratios. Again, no correlation (but these patients had an average K of 4.9).

A few other cases:

And secondofly — I’d have to disagree on Amal’s recommendation of bicarb.

Sodium bicarbonate does not work — or at least, does not work well, or on its own — for treating hyperkalemia. And in patients with fluid/volume issues (heart failure, renal failure — you know, the typical people who get hyperkalemic), I always worry about giving a big intravenous hyperosmotic sodium bolus to these patients (as my nephrology professor used to remind us — “water follows sodium”). (NB: This was brought to my attention by one of my co-chiefs, Kim Medlej, who finished a critical care fellowship last year at Harvard, and now practices in Lebanon, so all the credit is his.)

Quick summary: We’re all taught bicarb works within 30 minutes, by intracellular shift/exchange of potassium ions for hydrogen ions, yada yada yada. That really doesn’t appear to be the case. I think in the ED we’re sometimes taught to just give them an amp or two of sodium bicarb, but that appears to have NEVER been studied. In the crashing/dying patient, yes, I give sodium bicarbonate, but I’m otherwise skeptical of the benefit and worried about the harm.

All the studies have really looked at bicarb infusions over hours, and if there’s any change to be found, it’s maaaybe at the 6 hour mark (after 6 hours of bicarb infusion, in patients who are already getting dialysis). Other studies with bicarb infusions show no statistically significant change, either. (One study that took patients and put them on a high or low dose bicarb infusion for an hour actually found a higher potassium levels after the infusion.) Probably the best study (Blumberg, 1992) found only a 0.5-0.7 drop, but they then attribute half the drop to the expansion of the ECF due to all the sodium the patients got.

Insulin definitely works. Albuterol works (but the studies are small and they usually give a good 10-20mg of it nebulized). There have been a few studies looking at combining bicarb + either of these other methods, and it looks like the bicarb probably DOES have some synergistic effect (it lowers the potassium more than just, say, albuterol alone). But by itself? Bicarb is probably pretty worthless.

Reviewing the literature, it seems like the insulin/D50, albuterol (? Lasix, not much literature on it) methods are the way to go. I know before I read this literature I felt better because I’d given the person kayexalate, or I’d given them bicarb, but really, the other methods are much more likely to keep the patient alive on the floor for 6 hours while they await their dialysis, without putting them into florid fluid overload.

To the stable, no dysrhythmias or severe symptoms patients I tend to give:

  • Regular Insulin 10 units IV with 1-2 amps D50
  • Albuterol 10mg nebulized
  • Calcium Gluconate 1-2g IV
  • Lasix if they make urine (pick your dose)

I’ve summarized the literature and we can send you the articles if you’re curious:

Burnell, 1956 http://www.ncbi.nlm.nih.gov/pubmed/13367188 Looks like this is where a lot of it started. Many articles from the 70s/80s cite this one. There’s very little on their methodology, but they have some pretty cool graphs that show an inverse relationship between pH and serum potassium concentration.

Schwarz, 1959 http://www.ncbi.nlm.nih.gov/pubmed/13629781 Case series of hyperK patients who had EKG changes who got better with bicarb. (Some of them got calcium as well, others required “5-10 grams of bicarb a day,” others got bicarb + blood transfusion.)

Fraley, 1977 http://www.ncbi.nlm.nih.gov/pubmed/24132 Methods: Took 14 hyperK patients, gave them bicarb infusions over 4-6 hours. Checked K every hour. Results: Divided groups retrospectively into “constant pH” and “changed pH” groups. Both groups showed decreases in their potassium, ~1.6-1.8mmol/L (never seen this significant of a drop reproduced).

Blumberg, 1998 http://www.ncbi.nlm.nih.gov/pubmed/3052050 Methods: Took 10 HD patients, checked their K (along with other labs), gave them a bunch of different agents for changing K (bicarb, insulin, epi drip, regular dialysate), and then checked their labs after an hour. For bicarb, it was 8.4% in water, 4mmol/min, for 1 hour only. They also tried a isotonic bicarb infusion of 1.4%. Results: The K actually went UP after both bicarb infusions.

They conclude that bicarb didn’t work, but in the past it’s worked over longer periods of time. So then they do …

Blumberg, 1992 http://www.ncbi.nlm.nih.gov/pubmed/1552710 Methods: Took 12 hyperK (>5.8) patients on dialysis, gave a bicarb (8.4% in free water) infusion 4mmol/min x1 hour, then 1.4% bicarb in water infusion 0.5mmol/min hours 2-6 and checked potassium levels throughout the time on dialysis. Also checked an EKG. Results: Average K was 6.0. K dropped at 4-6 hours, by 0.5-0.7, and they believe that half of the drop is probably due to the huge sodium load and increase in the extracellular fluid compartment.

Allon, 1996 http://www.ncbi.nlm.nih.gov/pubmed/8840939 Methods: Took 8 HD non-HyperK patients, put them through different combinations to lower their K (bicarb infusion, saline infusion, bicarb+insulin, saline+insulin, bicarb+albuterol, saline+albuterol). Results: Bicarb or saline infusions didn’t work. Anything with insulin or albuterol the combination worked, lowered them from 0.5-0.8, depending on the group. Of note, bicacrb + albuterol worked better than saline + albuterol (see Kim, 1997).

Kim, 1997 http://www.ncbi.nlm.nih.gov/pubmed/8852501 Methods: Took 9 HD hyperK patients, gave them separate or combined bicarb infusions (1/2 hour long) along with nebulized albuterol, checked K before and after. Thought maybe there would be combined/synergistic effects of the two meds. Results: Bicarb alone didn’t change the potassium. Salbutamol alone dropped the K by 0.6, and salbutamol + bicarb dropped the K by 0.9.

Kaplan, 1997 http://www.ncbi.nlm.nih.gov/pubmed/9043534 Methods: Took 8 dogs, gave potassium infusion until they got conduction disturbances, then backed down on the K, and gave either bicarb infusion (1.05% over 1 hour), bicarb bolus (8.4% over 5 minutes, then saline), or “saline” therapy (hypertonic saline 8.4% bolus + normal saline). Measured K before and after. Results: Saline worked just as well as bolus. Infusion worked better than both (but not statistically significant). Change was 1-2mmol/L.

Review Articles:

Kim, 2002: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3054237/ Don’t recommend bicarb, especially as a single agent, especially in dialysis patients. “Should not be used.”

Weisberg, 2008: http://www.ncbi.nlm.nih.gov/pubmed/18936701 Definitely doesn’t work short-term, but might still be useful for temporizing hyperK. “It has now been clearly demonstrated that short-term bicarbonate infusion does not reduce PK in patients with dialysis-dependent kidney failure, implying that it does not cause K shift into cells. Infusion of a hypertonic or an isotonic bicarbonate solution for 60 mins has been shown to have no effect on PK in dialysis patients, despite a substantial increase in serum bicarbonate concentration.”

Rachoin, 2010: http://www.ncbi.nlm.nih.gov/pubmed/21661096 “When treating hyperkalemic patients, hospitalists should use sodium bicarbonate to potentiate urinary elimination of potassium and should consider administering it either with acetazolamide or a loop diuretic, anticipating a lowering effect after a few hours.26 It should be avoided in patients with volume overload and anuria. Immediate translocation of potassium into cells is best achieved by insulin and b-2 agonists.”

Would love to hear others’ thoughts!

05.23.13
by

Testes…testes…123.

My hand was shoved down, awkwardly positioned between the folds of trousers and half-pulled down underwear, in the man's groin crease, trying to palpate his testicles without pulling any of his pubic hair. Something didn't feel right, but it wasn't his testicles.

I was in my final surgical OSCE's and it was my first station, where the adrenalin was flowing and my mind was racing faster than my running commentary...

...and I would be checking to see if there were any hard lumps in the scrotum, or if I could not get above the swelling...

I had only just recovered from initially describing my landmarking for the deep inguinal ring as the "midpoint between the pubic trochanter and the anterior superior iliac spine" which caused my examiner to hover his pencil over the marking pad as I searched for the correct word that started with a "T".

TUBERCLE. Tubercle. Tubercle. Tubercle. Dammit. 

 Check.

Initially I hadn't been too flustered. It was a groin exam for a lump, which is pretty standard on a surgical final. But I didn't think that we'd be expected to actually tackle the tackle in the exam. I said the usual "Ideally I would like to expose the patient fully and perform a genital exam to complete my hernia assessment" and waited the beat for the examiner to butt in, rescuing the patient from a succession of 32 fumbling medical students.

Silence.

Maybe he hadn't heard me.

Ideally I would like to EXPOSE the patient fully and perform a genital exam...

Still nothing. So I went for it. Which is how I found myself rolling this 70 year old man's testicles around in my hand at 0905h on my last day of medical school, wondering WHAT it was that didn't seem right.

It wasn't until my rest station a few stops later that I saw, between a one inch crack in the curtain, a colleague pulling on a pair of gloves.

OH FUCK! 

That was what felt weird. I have been a nurse for 5 years and a medical student for 4. I put on gloves when I hear the ambulance bay doors open, even before I see the patient. So WHAT THE HELL WAS I THINKING DOING THE EXAM BARE HANDED?!?!? What felt weird was the fact that I didn't have a nice latex barrier between myself and that poor man's private parts.

I started wondering if maybe my mistake had been a red flag (i.e. cause for failure of my surgical OSCE's as a whole). When one of the emerg docs walked by and asked how I was doing during a later rest station I told her, "Well, pretty good for starting the day by ball handling without gloves, how's your day going? Do you think I red flagged???"

She said she couldn't be sure but told me not to worry as once during her emergency medicine exams she put in a chest tube without gloves (I'll point out that this involves sticking a FINGER INTO THE CHEST after you've made an incision in the rib cage). She did make me feel better.

Afterwards with some of my classmates during our postmortem on the exam I confessed to my ridiculous oversight. The color drained from one girl's face as she suddenly realized that she had done the same. Ohmygodohmygodohmygod. She seemed to be quite disturbed by this realization. It wasn't until much later in the evening when she had consumed a few celebratory pints that she approached me at the bar and confessed.

You know how freaked I got about not wearing gloves? Well...I couldn't tell you at the time because I was so mortified....but mostly the reason I was so upset was that when you said that I realised that right after that station I had EATEN A SCONE!!!!!








05.23.13
by

The heart of a lion

This is a column of mine, published at Girls Just Wanna Have Guns.

Here’s the link:  http://girlsjustwannahaveguns.com/2013/04/heart-of-a-lion/

 

 

I was getting ready for work one morning, around 6 am, when I heard soft footsteps on the stairs. My youngest son, then 11, emerged into the entry way.  He was stepping carefully and in his right hand was his favorite Cold Steel brand machete.

I asked, ‘so, what’s up?’  (I was a little afraid he was sleep walking and would make quick work of dear old pop before I could get to the ER to take care of other injured folks.)

He replied, ‘I heard noises but wasn’t sure who was down here.’

Bottom line?  He was ensuring his family was safe.  And woe to any poor soul who felt the wrath of his blade.

We had a chat.  I praised him for his bravery and then added a parental caveat:  ‘but, if you think we have an intruder, you must come and tell me or your mother.’

Like his siblings, he’s passionate and brave.  A student of history, he loves the idea of chivalry.  My children and I have had many long talks about courageous persons of the past, about battles and strategy and about the merits and disadvantages of ancient weapons.  My son’s walls, and the walls of his brothers, are festooned with assorted swords, axes, daggers and archery equipment.  Even little sister has a favorite blade, stored in her room in case of emergency.  (Don’t panic.  They’re unsocialized homeschoolers, so this is pretty normal in our world. Along with reading books that aren’t politically correct and going to school without bullies.)

Contrary to popular wisdom in the public school systems of the West and the lame-stream media, my kids are about as gentle and kind as any on earth.  Not that they aren’t capable of doing harm.  But you’d have to push pretty hard for them to launch a spear or tomahawk your direction.  And by that, I mean you would probably have to break into their home and threaten to harm them or the rest of the family.

I think there are some lessons here; and not just because I’m proud of my children.  The first lesson is this:  freedom can only be preserved when we teach our children valor.  This means explaining to them that there are times in life for bold, decisive, even dangerous action. There are times when it is appropriate to confront evil with force.  If we raise generations who believe that the most dangerous threat can be mitigated with hugs and negotiations, then freedom will die along with all of those who try to understand and dialog with tyrants and psychopaths.

Teaching valor involves telling stories of the past, talking about the news of the day, and providing our children with fitness and the sort of activities considered completely appropriate in centuries past; things like wrestling, boxing and marksmanship.

But here’s the second lesson.  Just as freedom must always be balanced by responsibility and accountability, so courage and valor must be kept in dynamic tension with morality and mercy, with kindness and gentility.  We cannot raise men, or women, capable of violence (and every human being is) if we deny the value of morals and ethics.  We may fight in the front yard with heavy plastic swords, shoot arrows at targets or shoot clay-pigeons with shotguns.  But we also discuss right and wrong through the lens of history and the teachings of our faith.

The world is dangerous.  And those of us who believe that self-defense is a right granted by the Creator, not sanctimoniously granted by politicians who think we’re peasants, also believe that we have to prepare our children for those dangers, moral and physical.

Much of the world disagrees with that assessment.  Oh, they know it’s dangerous.  But they don’t want anyone prepared to deal with it in any way other than calling 911 and waiting for the inevitable end.  Because of this, they want the masses disarmed.  But here’s what they don’t understand. Self-defense doesn’t reside in the weapon, but in the spirit.

This is what we have to teach our next generations.  Weapons are necessary to combat both tyrannical rulers and dangerous individuals.  Americans have developed a unique passion for the creation of weapons and the appropriate use of weapons.  But ultimately, the weapon is secondary.  The heart and mind are most important.

If we do that, if we teach right and wrong, if we teach freedom and justice, if we teach chivalry and courage, then the weapons themselves are not the issue. Trust the guy who saw the fire in the eyes of his son, who was prepared to clear the house of bad guys with nothing more than his machete…and the heart of a lion.

05.23.13
by

Internal Medicine Senior Poster

At the end of every year, the Intennal Medicine residency at Hennepin County Medical Center holds a poster session for the graduating senior residents. Each resident is encouraged to display work from their time during residency. Most residents prepare a poster on research they worked on or quality improvement projects. Others have shown off education innovations they came up with, or simulation cases they developed.

I enjoy sketching/drawing and have prepared many figures for the presentations, papers, lectures, blog posts, and teaching that I have done during my residency. I thought it would be fun and unique to prepare a poster with a sample of my art. Nothing earth shattering, but I hope you enjoy.

Bruen_IM_Senior_Poster_Session

05.23.13
by

Clinical Case 086: from Hell’s heart I stab at thee

Today’s case is a tough one.  This is not a happy story, but can you make it end well?

So lets lay it out and narrow it down to a few key decision points.

The patient is a 35 year old woman with a long history of schizophrenia – she has suffered with persecutory, paranoid delusions for many years.  She also has a tendency to use alcohol to “self-medicate”.  She is closely monitored by a community mental health team and has been managed under a community-treatment order for the last few years.

Recently she has been under a lot of stress and she has increased her alcohol use.  You have seen her in ED a few times with self-inflicted injuries resulting from delusional actions.

Tonight she has been brought in by ambulance after another delusional, self-inflicted injury….

Our patient has taken a long blade and hammered it into her sternum using a heavy torch.  This happened at least 2 hours ago.  On arrival tot the ED her obs are remarkably normal.

Apart from a bit of blood on her clothing there is little else to find other than a knife handle protruding from her anterior chest.

As you are assessing her she has a transient dip in her BP – down from 110/80 to 85/70.  This recovers without any intervention on your part.

So she gets some big IVCs, a cross match is sent, and the cardio-thoracic Reg is paged to attend ASAP.

ECGstab ECG

A quick FAST / ECHO show no fee fluid, no pneumothorax, and no pericardial effusion of any volume [no tamponade effect seen either] But…..  a spot troponin comes back at 0.18 – so must have some myocardial injury?

When the Surgical team arrives there is a case conference in the hallway….

They are keen to pull the blade in ED!  This seems like a bad idea…  after a bit of back and forth a CT is ordered

CT CHEST stab CT

Lets assume we are in a tertiary ED with all the usual resources – ICU, cardiac theatre, trauma surgeons etc….

There was a similar case presented on Life in the Fast Lane a few months ago which you should check out for reference. There is  a great “what would Weingart Do?” session around this case.

Here are a my questions for this scenario:

Q1:  The super keen CT Reg is reassured by your limited bedside ECHO, and the CT appears to show no cardiac injury.  He wants to give a bit of sedation and pull it out in ED – no point in bothering the nice Anaesthetic team….    what do you say to him?

Q2:  Imagine you are the Anaesthetic Reg called to do a pre-op assessment for this lady.  What is your basic plan to prepare for  this case?

Q3:  NOW, just as you are “discussing” the management paln with the CT Reg – the nurse rudely interrupts you to say: shes just gone unconscious and has no palpable pulse!   Ah, bugger.  What to do now?  This is one of those scenarios that Cliff Reid bangs on about - you need to have a premeditated plan.  What is yours?  What kit do you need?  Do you know where it is in your department?

Q4:  Whose famous last words are included in the title of this post?

OK gang.  First in best answer – you know the drill

Cover yourself in Broome Docs glory and get your answers in.  Love and respect are your rewards.

Oh, and keep you eyes open for the brilliant FOAMed goodness that you can now get as the SMACC 2013 lectures are released on iTunes and the various super blogs.  There will be a lecture from Dr Scott Weingart on “Just Crack the Chest” in the near future – I will link back to this post when it is available.

Casey

05.23.13
by

New lung cancer prediction tool promises better use of screening CT (NEJM)

New Prediction Model Selects Best Lung Cancer Screening Candidates In the National Lung Screening Trial (NLST), screening for lung cancer with low-dose chest CT scans resulted in a 20% reduction in death from lung cancer. The consumer-serving American Lung Association recommended that older people with heavy smoking histories should get lung cancer screening; leading professional societies [... read more]

The post New lung cancer prediction tool promises better use of screening CT (NEJM) appeared first on PulmCCM.

05.23.13
by

Umfrage zu medizinethischen Entscheidungen in der Notfallmedizin und Vorstellung der AG Ethik der DGINA

Wir erleben in unserer täglichen Praxis, dass es zwar deutschlandweit bereits gut funktionierende Strukturen klinischer Ethikberatung in Krankenhäusern gibt (Ethikberatung, Ethikkonsil, Ethikkomitee), dass diese Strukturen aber im akuten Notfall beim unverhofft in der Notaufnahme eintreffenden (und womöglich lebensbedrohlich erkrankten) Patienten ohne zuhandene schriftliche Äußerung (z.B. in Form einer Patientenverfügung) und ohne kontaktierbare Angehörige/Betreuer in der Kürze der zur Verfügung stehenden Zeit meist nicht anwendbar sind. Grund genug sich einmal genauer mit dem Thema zu befassen, da auch vorhandene Empfehlungen und Leitlinien (ERC, BÄK, DIVI u.a.)  meist nur zur Therapiebegrenzung im Verlauf, aber wenig zur Akutsituation in der Notaufnahme Stellung nehmen. Trzeczak,S: Notfallmedizin: Ethische Kompetenz und praktische Erfahrung. Dtsch Arztebl 2013; 110(15): A-706 / B-624 / C-624.

Im Rahmen der DGINA-Jahrestagung 2012 am 05.und 06.04. 2013 in Göttingen hat sich eine Arbeitsgruppe Ethik in der Notfall-und Akutmedizin gebildet, die sich mit dieser Problematik befassen wird, beginnend mit einer Umfrage zur Evaluation des Status Quo in den Notaufnahmen (Ethikkonsil, ethische Probleme bei Reanimation und mit Patientenverfügung, schriftliche Entscheidungshilfen).

Klicken Sie hier für die Umfrage

Mittelfristig erhoffen wir uns durch die Zusammenarbeit von Mitgliedern der DGINA und der AEM eine Synthese aus fachlicher Expertise (medizinisch, ethisch, rechtlich) einerseits und praktischer Erfahrung aus der täglichen Arbeit in der Notaufnahme (Ärzte, Schwestern, Rettungsassistenten) andererseits, die helfen kann, die Probleme sowohl mit dem nötigen Abstand zu beleuchten als auch praktikable Lösungen zu finden.

Ziel sollen Handlungsempfehlungen oder Entscheidungshilfen medizinethischer Art für Problemfälle in der Notaufnahme sein, aber auch die Schulung der in der Notaufnahme Tätigen in medizinethischen Fragen.

Geplant ist das erste Thema “Der in der Notaufnahme eintreffende nicht ansprechbare Patient am Lebensende in der Akutsituation” für 2014 fertig- (Handlungsempfehlungen, Schulungsinhalte, Veröffentlichung) und einen ersten Zwischenbericht auf der DGINA-Jahrestagung im Dezember 2013 vorzustellen.

Weitere Themen, wie z.B. der psychisch kranke Patient, der alkoholisierte Patient, Umgang mit Psych-KG, Gewaltopfer in der Notaufnahme, Gewalteskalation in der Notaufnahme, ethische Aspekte beim Massenanfall von Verletzten und ethische Aspekte von Triage und Allokation können später folgen.    

 

Copyright © 2013 by DGINA e.V.
This feed is for personal, non-commercial use only.
The use of this feed on other websites breaches copyright. If this content is not in your news reader, it makes the page you are viewing an infringement of the copyright. Digital Fingerprint: 678345985D53467G45367I56478N35782A

Thematisch passende Beiträge

05.23.13
by

PV Card: Contraindications to Thrombolytics in Stroke


This PV card is an updated version of the PV card on Thrombolytic Contraindications for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published. Some changes include:

  1. There is new mention of new anticoagulants in the market with additional absolute exclusion criteria.
  2. A blood glucose < 50 mg/dL has been upgraded from a relative exclusion to an absolute exclusion criteria. There is no more mention of glucose > 400 mg/dL as an exclusion criteria.
  3. Seizure at onset of presentation has moved from an absolute to a relative risk.
  4. Post-AMI pericarditis is no longer a relative exclusion criteria.



Feel free to download this card and print on a 4'' x 6'' index card.


Reference
Jauch EC, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. PubMed PMID: 23370205. Free article PDF
05.23.13
by

The Crashing Asthmatic

UPDATE:

Since making this, StEmlyns have scuppered my take on Mag by reporting the 3MG trial which gave a big great ‘hmpph’ to mag and suggest very little, if any benefit. Check out their take. 

In my current dept, there’s a monthly joint ICU/ED meeting. I recently presented on some of the evidence base and strategies for managing life-threatening asthma. The 15 people there seemed to enjoy it so now i’m sharing it with the rest of the #FOAMed community.

I’ve included some references below from some of the papers cited in the talk.

Two talks in particular deserve mention.

One on EM:RAP by Mel Herbert himself back in 2007 [subscription needed] and the other from EMCrit.

Lim, Wei Jie, Redhuan Mohammed Akram, Kristin V Carson, Satya Mysore, Nadina A Labiszewski, Jadwiga A Wedzicha, Brian H Rowe, and Brian J Smith. “Non-Invasive Positive Pressure Ventilation for Treatment of Respiratory Failure Due to Severe Acute Exacerbations of Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD004360. doi:10.1002/14651858.CD004360.pub4.

Mohammed, S, and S Goodacre. “Intravenous and Nebulised Magnesium Sulphate for Acute Asthma: Systematic Review and Meta-Analysis..” Emergency Medicine Journal 24, no. 12 (December 2007): 823–830. doi:10.1136/emj.2007.052050.

Nair, Parameswaran, Stephen J Milan, and Brian H Rowe. “Addition of Intravenous Aminophylline to Inhaled Beta(2)-Agonists in Adults with Acute Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD002742. doi:10.1002/14651858.CD002742.pub2.

Rowe, B H, J A Bretzlaff, C Bourdon, G W Bota, and C A Camargo. “Magnesium Sulfate for Treating Exacerbations of Acute Asthma in the Emergency Department..” Cochrane Database of Systematic Reviews (Online) no. 2 (2000): CD001490. doi:10.1002/14651858.CD001490.

Tobin, A. “Intravenous Salbutamol: Too Much of a Good Thing?.” Critical Care and Resuscitation : Journal of the Australasian Academy of Critical Care Medicine 7, no. 2 (June 2005): 119–127.

“British Guideline on the Management of Asthma” (February 2, 2012): 1–151.

CORSSEN, GUENTER, JUAN GUTIERREZ, JOSEPH G REVES, and FRANCIS C HUBER. “Ketamine in the Anesthetic Management of Asthmatic Patients.” Anesthesia & Analgesia 51, no. 4 (1972): 588–594.

 

The post The Crashing Asthmatic appeared first on Emergency Medicine Ireland.

05.23.13
by

no bones about it…

The case.

A 15 year old male is bought to ED by his mother with a complaint of throat pain after eating a meal of chicken skewers that were cooked on the family barbecue. He is alert and in no apparent distress, breathing comfortably without stridor or drooling. His observations are within normal limits and his chest is clear to auscultation.

The skewers were prepared at home from chicken breast and they “are pretty sure there were no bones around” ….

I ordered a CXR.

CXR

CXR (marked) CXR (wire FB)

      • Metallic-appearing foreign body in the superior mediastinum. 

      • Where is this ?!
          • Most likely oesophageal given the history.
      • It needs to come out ?!
          • Gastroenterology agree & will review the patient, however they ask for a CT with the question “Has it caused any damage ?!”

CT03 CT02 CT01

Approximately 80% of swallowed FBs are in children (aged 1-4 years). This will involve toys & coins for example and will lodge in the anatomically narrowed parts of the oesophagus. Adult patients generally provide an unequivocal history but can occasionally present with unintentional ingestion (eg. dentures). Adult impactions tend to be more distal.

Signs & Symptoms.

      • Throat or retrosternal pain.
          • Localization of the object based on symptoms is rarely accurate.
      • Dysphagia, vomiting, gagging.
      • Children; refusal to eat/drink, vomiting, drooling, stridor, gagging.

Diagnosis.

      • Plain X-ray can screen for radiopaque objects.
          • Eg. Coins will face forward on AP films (generally face-on in lateral films for tracheal placement).

Coin Lateral Coin AP

      • Bones are only seen on X-ray < 50% of the time.
      • CT is a high-yield test.
          • Provides information on location as well as associated perforation or subsequent infection.

Management.

      • Resuscitation [including airway protection with ventilatory & haemodynamic support].
          • Aspiration risk with secretion buildup from complete obstruction.
      • Emergent endoscopy is required
          • Instances requiring urgent endoscopy;
              • Airway compromise
              • Sharp or elongated objects
              • Multiple FBs
              • Button batteries
                  • Potential for mucosal injury or necrosis & perforation.
              • Two or more magnets.
              • Evidence of perforation
              • Coin at cricopharyngeus muscle
              • FB for > 24 hours.
          • Endoscopy allows removal of the majority of objects.
      • Indirect laryngoscopy or fibreoptic visualization may be helpful for proximal objects.
      • Other techniques;
          • Foley-catheter pulling object backs to oropharynx.
          • Bougie to advance objects further into the stomach.
          • Should only be used if object is blunt & lodged for < 24 hours.
      • Glucagon:
          • Controversial. No better than ‘watchful waiting’. Promotes unwanted vomiting.
      • Objects beyond the pylorus…
          • If shape or make is not of concern then treatment is expectant.
          • If this is deemed inappropriate surgical referral must be made.

 

Sharp Object Ingestion.

      • Need immediate removal (if proximal to duodenum)
          • Intestinal perforation is common (~35%) when sharp objects pass distal to stomach.
      • If object is distal to duodenum, then daily X-rays are required to document passage.
          • Failure to pass object > 3 days requires surgical opinion.

      • Concerning proximity of the FB to mediastinal structures.
      • Appropriate surgical teams notified at time of endoscopy in case of vascular catastrophe.
      • An uneventful scope takes place a few hours later with successful retrieval of a small metallic wire frond.
      • It turns out the barbecue was rather dirty prior to cooking and the father had scaled off the old material with a wire brush (a dislodged frond had then made its way into/onto a chicken skewer).

05.23.13
by

TechTool Talk 004

As part of TechTool Thursday, I thought it would be interesting to look at more than just app reviews.  This week I interview Adrian Bonsall

Adrian BonsallAdrian Bonsall is a Paediatric Emergency Fellow at Sydney Children’s Hospital.  Prior to studying medicine he worked as a computer programmer and systems analyst in the UK

When did you start becoming involved in health IT?

I’ve been programming since the first personal computers were available over 30 years ago.  Whilst a medical student I wrote programs that integrated a GP surgery’s software and developed revision aids.  Later I wrote a paediatric resuscitation scenario builder and a rostering software

What led to you start your rostering software? 

It began in 2001, when my then Emergency Department director was bemoaning the trials of devising a JMO roster which didn’t lead to a string of complaints about inequality, not meeting the current award or double-bookings.  I thought a simple 6-step process might be the way to lead even the least savvy computer user through to a better roster.  The Roster Wizard has been employed at about a dozen major hospitals, mainly in NSW, but also in Northern Territories, Queensland and the UK

Have you been involved in any other health IT projects?

A few.  I developed a Paediatric Resuscitation Calculator for drug doses & equipment sizes and it has been extensively used at Sydney Children’s Hospital and now further afield.  In 2011 I designed & built the Children’s Emergency Department website for the Mater Children’s Hospital in Brisbane and am now trying to revitalise the Sydney Children’s Emergency Department intranet site.  I have also ‘donated’ my revision notes (~350 topics) for the ACEM Part II exam, which I try to keep updated on my own embarrassingly under-constructed site (ambonsall.com).  I also write little web calculators for topics such as Burns fluids, Paediatric Growth centiles, and DKA fluids

Don’t you find implementing health IT in hospitals is a bureaucratic nightmare?

The three main issues I have encountered are: the meeting merrygoround that seems necessary to get anything approved; hospitals with their own IT departments can show some resentment and obstruction; and getting paid for professional work done whilst holding on to one’s intellectual property can be problematic

What do you enjoy most about health IT?

I really enjoy programming and breaking down the problem in a logical manner.  To me building my own software is a creative outlet, even if many other programmers have done it similarly in the past. 

What are you careers aims for the next 10 years?

I would like to have the time and resources to tackle another couple of large projects.  The current solutions to the Electronic Medical Record that I have used in emergency departments are slow, needlessly complicated, do not appear to save time for clinicians who have to input the data in real life practice, and have problems with integration with other hospital systems

What is the best piece of advice you’ve been given?

Don’t give interviews

 

The post TechTool Talk 004 appeared first on Life in the Fast Lane medical education blog.

05.23.13
by

La atención médica no puede ser condicionada a un cheque en garantía

El prestador de salud debe entregarte sus servicios de urgencia sin excepción

 


El paciente que llega a un servicio de urgencia en situación de riesgo vital debe ser atendido inmediatamente. Su atención no puede ser supeditada de modo alguno a la exigencia de un cheque, de dinero o cualquier otro medio de pago por esas prestaciones. La ley Nº 20.394 prohíbe y sanciona al servicio médico que no atiende a un paciente en riesgo vital. Lo mismo ocurre en caso de prestaciones programadas, la diferencia está que en este caso sí te podrían solicitar la firma de un pagaré. Recuerda, el prestador que niega o restringe una atención de urgencia a la entrega de un cheque en garantía o dinero en efectivo, está actuando en contra de la ley y este hecho puede ocasionarle importantes sanciones. En ese caso tu tienes la posibilidad de presentar un reclamo ante la Superintendencia. 

Tomado de Web de Superintendencia

05.23.13
by

The Australian response to gun violence…less is more

This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.

 


05.23.13
by

Uluslararası Akademisyen Gelişimi ve Eğitimi Kursu (IEMTC13)

Uluslararası Akademisyen Gelişimi ve Eğitimi Kursu, Baltimore, ABD’de bu sene ikinci kez 21-25 Ekim 2013 tarihleri arasında yapılacak. Acilci.Net olarak 3, Türkiye’den toplam 5 kişiyle ilkine katıldığımız bu organizasyonda Amal Mattu, Rob Rogers, Mel Herbert, Mike Bond, Haney Mallemat, Mike Stone, Mike Cadogan gibi isimler yer alıyor olacak.

Amal Mattu’yu EKG serilerimizden takip ediyorsunuzdur. Mike Cadogan’da Acilci.Net Uluslararası Editörlerinden ve LifeInTheFastLane ve GMEP FOAM sitelerinin kurucularından. FOAM hareketini başlatan isimlerden. Haney Mallemat tam bir kadavra laboratuvarı ustası. ROb Rogers iTEachEM FOAM sitesi editörü. Dolayısıyla da bu kurs aslında FOAM hareketine kendini adamış bir akademisyenin alması gereken tüm içeriği kendisine ulaştırıyor olacak.

Eğer Asya Acil Tıp Kongresi’ne gitmiyorsanız Wired dizisiyle aklımızda yer eden Baltimore’u yakından görün derim. John Hopkins, Mercy ve Maryland kampüsleri bu şehirde ve birbirine çok yakın. New York 2 saat, Washington DC 1 saat uzakta. Dolayısıyla kurs önü ve arkasında 1-2 gün koyarak neredeyse doğu yakasının önemli tüm acillerini de ziyaret etme fırsatı bulabilirsiniz.

İlk tanıtım broşürü aşağıda yer alan bu kursla ilgili gelişmeler oldukça buradan duyurmaya devam edeceğiz.

Ana sayfamızda bu kursun linki de sabit linklerimiz arasında, kurs web sitesine buradan ulaşabilirsiniz.

 

Download (PDF, 3.2MB)

Diğer Yazılar

  • Uluslararası Acil Tıp Eğitici Kursu, Baltimore, Maryland – 21-25 Ekim 201327/12/2012 -- Uluslararası Acil Tıp Eğitici Kursu, Baltimore, Maryland – 21-25 Ekim 2013 (0)
    Uluslararası Acil Tıp Eğitici Kursu 2013 (International Emergency Medicine Teaching Course) 2. defa Maryland Üniversitesi yerleşkesinde ABD'nin Baltimore kentinde 21-25 Ekim tarihleri arasında yapı...
  • Life in the Fast Lane27/12/2012 -- Life in the Fast Lane (0)
    FOAMed nedir? Nerede başladı? Acil Tıp eğitimini her an tüm elektronik sosyal medya araçlarını kullanarak devam ettirmek mümkün mü? Dünya değişiyor, eğitim de... İşte FOAMed bu yeni değişen düny...
  • TATKON2013 web sayfası yayında24/04/2013 -- TATKON2013 web sayfası yayında (0)
    Değerli Acil Tıp profesyonelleri, merhaba! Türkiye Acil Tıp Derneği olarak sizlere unutamayacağınız bir kongreyi sunmaktan büyük bir heyecan duyuyoruz. 9. Türkiye Acil Tıp Kongresini 2-6 Ekim 20...
  • KADAT2013 – MAYIS – Eskişehir12/05/2013 -- KADAT2013 – MAYIS – Eskişehir (0)
    Kanıta Dayalı Acil Travma Yönetimi Kursunun (KADAT) 5. yılında yine sizlerleyiz. Mayıs 2013'te Eskişehirde gerçekleşen kursumuzda 30 kursiyer katıldı ve 15 eğitimen görev aldı. Son derece dinami...

The post Uluslararası Akademisyen Gelişimi ve Eğitimi Kursu (IEMTC13) appeared first on acilci.net.

05.23.13
by

20 Things Changing EM: THE SILVER TSUNAMI

Reblogged from NJEmergencyDocs:

Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post
  • Click to visit the original post

This is part of a continuing series exploring the Confusing array of changes to healthcare and identify the Opportunities for our specialty. The goal is to give you three things:

  • The What
  • The Why
  • The Opportunity (for our emergency medicine)


There is a tidal wave that is coming. The baby boomer generation (those born 1946-1964) are now entering retirement age. Combined with increases in life expectancy it is causing an unprecedented  "graying" of the United States and most other industrialized countries.

Read more… 544 more words

Second in the NJ-ACEPs series about what is affecting our specialty. Worth the read.
05.23.13
by

Why you need to come and see this at AirSupport – the Vital Link, 28-30th August 2013 Melbourne

Dr Brian Burns, Dr Karel Habig & Dr Cliff Reid of GSA HEMS, NSW Ambulance. What are they looking at so seriously?

 

Dr Peter Sherren and SCAT Paramedics from the GSA HEMS team, first up in the inaugural Aeromedical Simulation Cup 2012

 

The winning team ( Dr Andrew Pearce with flight nurses) from MedSTAR, Adelaide in 2012. Come and see them defend their crown in August 2013, Melbourne!

 

AIR SUPPORT- THE VITAL LINK, CONFERENCE WEBSITE


Filed under: Aeromedical retrieval, Emergency medicine and critical care Tagged: 2013, aeromedical, August, conference, Melbourne
05.22.13
by

L’attenzione del TRIAGISTA

  Ore 8 del mattino di una assolata domenica estiva. Il turno di guardia al triage è cominciato da poco e, come tutte le domenica mattina, l’afflusso in pronto soccorso è, per fortuna, abbastanza lento Un anziano paziente di 86 anni entra in area triage e riferisce episodi di melena ripetuti. Il rilievo dei parametri [...]

The post L’attenzione del TRIAGISTA appeared first on EM Pills.

05.22.13
by

WWWTP #7 (What’s Wrong With This Picture)

This patient came in with abdominal pain.  An upright chest Xray was ordered to eval for free air.  Can you see any abnormalities?

Guidewire chest

What’s wrong with this picture? (HINT: you may need to zoom in on the cardiac silhouette and mediastinum to see the abnormality)

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  Aaron Hougham MD


Filed under: WWWTP
05.22.13
by

Autopulse Advertisement in Critical Care Medicine

We've all seen folks come in via EMS with mechanical devices performing automated chest compressions.  These probably do a lovely job of freeing up paramedics from performing uninterrupted CPR, but their relationship to outcomes has been typically uncertain.

This meta-analysis and systematic review, however, reports these devices are superior to manual chest compression – with an OR of 1.6 towards increased return of spontaneous circulation.  Considering the copious evidence towards improved outcomes by minimizing interruptions during CPR, this would be an important finding, and tailors nicely with the expected advantage of mechanical compression devices.

However, this COI statement covering each of the four authors might also be in some fashion related to the positive results reported here:
"Dr. Westfall has received modest research grant support from ZOLL Medical Corporation. Mr. Krantz has received significant research grant support from ZOLL Medical Corporation. Mr. Mullin has served as a consultant for ZOLL Medical Corporation. Dr. Kaufman is an employee of ZOLL Medical Corporation."

Unsurprisingly, these authors also demonstrate one of the overlooked evils of meta-analyses – the obfuscation of source COIs.  This JAMA article from 2011 does a lovely job describing this critical problem, and, as expected, these conflicted authors ignore the pervasive sponsorship bias present in their selected review.  Additionally, half the articles are only conference abstracts, suffering from results and methods not subject to the same level of rigorous peer review.

It really ought to be rather embarrassing for the editors of this journal to be approving such a clearly flawed vehicle – essentially blatant advertising for their $15,000 medical device – for publication.  No better, Journal Watch Emergency Medicine gives this article a bland and un-insightful thumbs-up.

"Mechanical Versus Manual Chest Compressions in Out-of-Hospital Cardiac Arrest: A Meta-Analysis"
www.ncbi.nlm.nih.gov/pubmed/23660728‎
05.22.13
by

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias




The Case
A 56 y/o man presents to the ED via ambulance. He was sent from clinic for 'new onset afib.' His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to 'rate control' the patient with a goal heart rate < 100 bpm.

The Clinical Question 
Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension. 

What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?

The Data

The following table only includes studies where patients received calcium before the calcium channel blocker:


Citation
Study Design
N
Drug
Calcium Form/Dose
Results
Weiss AT, et al. Int J Cardiol 1983; 4:275-84.
Prospective
13
Verapamil
Calcium gluconate 1 gm
SBP ↑ 5 mm Hg
Roguin N, et al. Clin  Cardiol 1984; 7:613-6.
Case series
2
Verapamil
Calcium gluconate (pediatric pts)
No hypotentsion
Haft JI, et al. Arch Intern Med  1986; 146:1085-9.
Sequential study of 2 treatment protocols
50
Verapamil
CaCl 1 gm
SBP ↑ 2 mm Hg
Salerno DM, et al. Ann Intern Med  1987; 107:623-8.
Sequential study of 2 treatment protocols
5
Verapamil
Calcium gluconate 1gm
SBP ↓ 12 mm Hg
Stringer KA, et al. Drug Intell ClinPharm 1988; 22:575-6.
Case Report
1
Verapamil
CaCl 1gm
No hypotension
Barnett JC, et al. Chest 1990; 97:1106-9.
Prospective report of protocol
19
Verapamil
Calcium gluconate 1gm or CaCl 1gm
SBP ↑ 4 mm Hg
Kuhn M, et al. Am Heart J 1992; 124:231-2.
Retrospective chart review
18
Verapamil
Calcium gluconate 3gm or CaCl 1gm
No hypotension
Miyagawa K, et al. J Cardiovasc Pharmacol  1993; 22:273-9.
Sequential study of 2 treatment protocols
7
Verapamil
Calcium gluconate 3.75 mg/kg
SBP: no change






Kolkebeck T, et al. J Emerg Med 2004;  26(4):395-400.
Prospective, randomized, double-blind, placebo-controlled
34
Diltiazem
CaCl 0.333 gm
SBP ↓ 8 mm Hg (placebo had SBP ↓14 mm Hg)
  SBP: systolic blood pressure
  CaCl: calcium chloride

Clinical Impact
The data supports administering calcium before verapamil to prevent hypotension, without negatively impacting the desired rate control effect.

There has been only one study trying this approach with diltiazem (Kolkebeck 2004). Although there was NOT a statistically significant difference, the group that received calcium did have less of a blood pressure decrease than the group receiving placebo (SBP difference -8 vs -14 mm Hg). 

LimitationsThe biggest weakness of this study, to me, is that the authors used the manufacturer-recommended dose for diltiazem of 0.25 mg/kg first (max 20 mg), then 0.35 mg/kg (max 25 mg). This dose is rather large and often causes hypotension. The authors note limitations including the small sample size, the convenience sample design, and that a low dose of calcium was used (333 mg of 10% calcium chloride, 90 mg elemental calcium).

Why not use smaller doses of diltiazem starting at 5 or 10 mg and repeat as needed? We have had good success using this approach with diltiazem combined with pre-treatment calcium gluconate 1-2 gm. Others have utilized diltiazem infusions without a bolus to avoid the hypotensive effects. This approach allows for slow titration and the option to stop (or slow) the infusion if hypotension occurs.

Still others might argue to just give metoprolol. Actually, calcium channel blockers have performed admirably versus beta-blockers in this scenario and are recommended as first line (more to come in a future post).



Conclusions
  • Although most of the data is with verapamil, administering calcium before diltiazem may prevent some of the hypotension. 
  • There currently isn't much published data for diltiazem. The one study, which was a negative one, had some limitations. 
  • The appropriate calcium dose is unknown, but 90 mg of elemental calcium (calcium gluconate 1 gm or calcium chloride 0.333 gm) is often used. We use 1 or 2 gm of calcium gluconate.
- Bryan Hayes, PharmD 
( @PharmERToxGuy)

Reference
Moser LR, et al. The use of calcium salts in the prevention and management of verapamil-induced hypotension. Ann Pharmacother 2000;34:622-9. [PMID 10852091]
05.22.13
by

Recommandations diététiques en cas de calculs rénaux

Les mauvaises habitudes alimentaires représentent une cause majeure dans la formation des calculs calciques, oxaliques et uriques. Les mesures diététiques concernent les boissons et l’alimentation.

Boisson

Le plus important est de boire en quantité suffisante. Cela dilue vos urines et diminue le risque de former des calculs. Vous buvez suffisamment si vous urinez 2 litres par jour.

Combien faut-il boire ?

  • 2 litres par jour, plus s’il fait chaud ou si vous faites une activité physique

Quand faut-il boire ?

  • Tous les jours, en répartissant régulièrement les boissons sur toute la journée
  • Incluant le soir au coucher
  • Et la nuit si vous vous réveillez

Que faut-il boire ?

  • Tous les liquides sont autorisés: l’eau du robinet ou en bouteille, un café, une tisane…
  • La quantité des boissons est plus importante que la qualité
  • Deux verres de jus d’oranges pressées sont conseillés

Quelles boissons consommer avec modération ?

  • Le thé trop fort, les boissons sucrées ou salées, le lait, la bière
  • L’alcool

Alimentation

Il ne s’agit pas d’un régime, mais d’un ajustement de vos habitudes alimentaires.

Les excès de calcium, sel, sucre, protéines animales, oxalate et acide urique favorisent la formation des calculs.

Apports en calcium

  • Le calcium vient des produits laitiers et de l’eau
  • Il ne faut ni trop, ni trop peu de calcium
  • les apports doivent être de 800 mg à 1 gramme par jour
  • Il es recommandé de prendre 2 à 3 portions de produits laitiers par jour selon la quantité de calcium de votre eau (voir étiquette)
  • 1 verre de lait (15 cl) = 1 yaourt = 100 g de fromage blanc

Teneur en calcium des produits laitiers

Produit laitier Teneur en calciumen mg/ 100 g
Petits suisses 100
Lait entier ou demi-écrémé 120
Brie, chèvre frais, fromage blanc 120-160
Crèmes glacées 150
Yaourts 150
Chèvre sec, Munster, Coulommiers 200-250
Camembert, Bleu 450
Roquefort, Cantal 600-700
Gouda, Edam, Comté, Gruyère 900-1000
Emmental, Parmesan 1200

Teneur en calcium de certaines eaux (liste complète sur www.aquamania.net)

Nature de l’eau Teneur en calciumen mg/ Litre
Volvic® 10
Evian® 78
Eau de source 10 à 120
Perrier® 150
Eau de ville 30 à 120
Badoit®, Vittel® 160-202
Contrexéville® 451
Hépar® 600

La teneur exacte en calcium est celle qui figure sur l’étiquette

En pratique: vous calculez puis vous choisissez

  • Si vous buvez 2 litres d’eau pauvre en calcium (moins de 20 mg/L), vous devez consommer environ 800 mg de calcium sous forme de produits laitiers.
  • Si vous buvez 2 litres d’eau riche en calcium (plus de 400 mg/L), vous devez limiter la consommation de produits laitiers.

Apports en sel

  • L’excès de sel alimentaire augmente la natriurèse (quantité de sel dans les urines) qui favorise l’excrétion de calcium dans les urines
  • Il faut limiter les aliments et les repas trop salés (charcuterie ,restauration rapide, plats cuisinés tout prêts)
  • Ne jamais ajouter de sel à table

Apports en protéines animales

  • Les protéines animales sont apportées par la viande, le poisson, la charcuterie et la volaille
    100 g de viande correspondent à 100 g de poisson
  • Il ne faut pas manger plus de 150 g de viande ou de poisson par jour. Il est plus simple de ne prendre qu’un repas de protéines animales par jour

Apports en oxalate

  • Les aliments riches en oxalate doivent être consommés avec modération: en particulier le chocolat et le cacao
  • Mais aussi: cacahuètes, noix, noisettes, amandes, asperges, betteraves, rhubarbe, épinards, oseille, thé, figues
  • La vitamine C en grande quantité (500 mg à 1 g) est déconseillée

Apports en acide urique

  • Il faut limiter les aliments apportant de l’acide urique: charcuterie, abats (ris de veau, rognons, cervelle, foie…), gibier, certains poissons (hareng, thon, sardine à l’huile, anchois…) et les fruits de mer
  • Consommer régulièrement des fruits et des légumes
  • En cas de calculs d’acide urique, une eau alcaline riche en bicarbonate est conseillée

En résumé

  • Boissons: 2 litres par jour, répartis sur la journée et la nuit + 2 verres de jus d’oranges
  • Calcium: 800 à 1000 mg par jour
  • Protéines: Pas plus de 150 g de viande ou poisson
  • Sel: Ne jamais ajouter de sel à table
  • Oxalate: Eviter les aliments riches en oxalate: chocolat, cacao et cacahuètes
  • Acide urique: Eviter la charcuterie, les abats et le gibier
  • Sucres: Eviter les sucreries, les bonbons, les pâtisseries et les sodas

Maintenez une activité physique régulière

Evitez l’excès de calories

Variez l’alimentation et consommez des fibres (fruits et légumes)

Ces règles diététiques sont simples

Elles doivent être respectées à vie

Elles sont plus efficaces si vous buvez plus de 2 litres par jour

Elles réduisent fortement le risque de récidive

Suivre ces règles diététiques réduit également le risque d’hypertension artérielle, de diabète et d’obésité

BUVEZ, BUVEZ ENCORE, MANGEZ MOINS et MANGER MIEUX

cela diminue le risque de faire ou de refaire des calculs

Voir aussi

Calcul rénal d’oxalate de calcium

Guide pour la prophylaxie de la lithiase urinaire

Anomalies biologiques retrouvées lors d’un bilan de lithiase urinaire

Source

www.urofrance.org


05.22.13
by

Tiny Tips: START Protocol for Mass Casualty Triage

My residency program discussed the EMS chapters in Rosen’s tonight and went over the START protocol for triage in mass casualty incidents.

For the unacquainted, START stands for Simple Triage And Rapid Treatment. This protocol aims to make triage extremely fast and simple to allow first responders to quickly assess large numbers of patients. Triaged patients are clearly marked with colors (black = dead, red = immediate attention, yellow = delayed attention, green = minor injuries).

As a mass casualty protocol may need to be taught to a large number of people quickly, it also needs to be intuitive. Unfortunately, in looking over the description in Rosen’s, I didn’t find that to be the case. Anyone that has read about this system in the past would have reviewed a flowchart that looks something like this:

startflow1

Like some of the other Tiny Tips that I have/will publish, it is unlikely that emergency physicians will need to memorize this. However, it certainly could appear on a resident’s Board exam. My goal with the Tiny Tips is to find a way to remember things for these exams that I do not find intuitive. This flowchart definitely fit the bill.

A quick search found me the mnemonics 30-2-Can Do and RPM (Respirations, Perfusion, Mental Status) to help remember the criteria. This seems like a reasonable way to teach the system, but it didn’t stick with me very well. Instead, I decided to remember it by sticking with the absolute basics because the flowchart is really just the ABC’s complicated by arrows and colors. Here’s what my revised START flowchart looks like:

BoringEM START Tool

While this method of remembering the START triage system still requires memorization of some findings, I found that merging it with my regular assessment system (ABC!) was more intuitive than trying to remember an incomplete rhyme (30-2-Can Do) and relating those numbers to speed (RPM). Using the START protocol this way, the relationship between the criteria and the assessment of the ABC’s can be clearly seen.

This memory device, as well as the rest of the Tiny Tips, have been made into flashcards that can be downloaded and used as outlined on the Boring Cards page. Check them out!

Author information

Brent Thoma
Emergency Medicine Resident at University of Saskatchewan
A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.
TwitterFacebookGoogle+LinkedIn

The post Tiny Tips: START Protocol for Mass Casualty Triage appeared first on BoringEM and was written by .

05.22.13
by

ECG of the Week – 20th May 2013 – Interpretation


This ECG is from a 64 year old male. 
Presented following multiple episodes of syncope.




Click to enlarge

Rate:
  • ~42 bpm mean ventricular rate
Rhythm:
  • Irregular
  • Junctional escape rhythm 
    • Complexes number 1, 3, 4, 5
    • Rate ~ 36 bpm
  • Sinus 
    • Complexes number 2, 6, 7
Axis:
  • Normal (~70 deg)
Intervals:
  • PR - Upper limit normal where present (~200ms)
  • QRS - Normal (100ms)
  • QT - 520ms
Segments:

  • ST Sagging leads II,III,aVF,V5-6

Additional:
  • T wave notching in leads V1-3 in 5th complex likely secondary to lead transition
  • Biphasic T wave V1
  • P waves broad & notched
Interpretation:
  • Intermittent sinus arrest with junctional escape rhythm

What happened ?

This ECG was captured during a symptomatic episode of presyncope. 
The patient then spontaneously reverted to sinus rhythm after a few minutes.
His beta-blocker was ceased and he was transferred for PPM insertion.

VAQ Corner

A 64 year old male presents to your ED following an episode of syncope.
He complains of feeling lighted. 
BP 105/60 RR 18 Sats 96% Room Air

a) Describe & interpret his ECG (50%)
b) Outline your management (50%)

References / Further Reading

Life in the Fast Lane
  • Sinoatrial exit block here
  • Sick Sinus Syndrome here
Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.